A Prescription for Mindfulness

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The prescription is a powerful tool for a physician. As rheuma­tologists, we prescribe many things—drugs, physical therapy, durable medical equipment—but what about stress reduction? We are very specific about times of day to take medications and in what manner. Patients ask: With or without food? With other medications? Before or after other prescribed medications? If we can plan someone’s methotrexate down to the minute, we can also prescribe a stress-reducing, meditative exercise at times of increased need.

Exposure to stressful situations coupled with poor coping strategies have been shown to be associated with increased pain and disease activity in rheumatoid arthritis (RA).^1-3 Upon hearing anecdotal accounts of patient stressors daily, I recognized that prescribing stress reduction to alleviate anxiety in the exact same fashion may be helpful.

Based on our preliminary data, patients with high perceived stress and anxiety may benefit from prescriptive stress-reduction techniques to better cope with their rheumatic disease.^4,5 Stress reduction techniques, specifically meditation, may, in theory, down-regulate the inflammatory response and pro-inflammatory cytokine production that can come along with psychological stress.⁶

For patients with emotional distress driven by ineffective coping strategies or poor self-efficacy, non-pharmacologic treat­ment strategies, such as mindfulness-based interventions, may be ideal. Self-efficacy is people’s beliefs in their ability to succeed at specific goals and tasks. Regarding chronic disease, this is particularly important when it comes to managing medications, symptoms, difficult emotions, daily activities and social interactions.

We sought to better understand patient stressors and curate a series of meditations geared toward improvements in self-efficacy and reduction of perceived stress.

What Is Mindfulness?

Mindfulness is a mental state defined as non-judgmental awareness of the present moment and involves self-regulation of attention guided by curiosity, openness and acceptance.⁷ Mindfulness-based interventions are well-established, self-management interventions that focus on learning how to mindfully respond to bodily sensations and emotions through guided meditative practices.

Traditional office-based, mindfulness-based interventions run several weeks to months and are typically led by psychol­ogists or certified instructors.^8,9 However, the time-consuming nature of the various mindfulness-based interventions makes participation difficult for those in the workforce, with limited means of transportation or with caregiver duties.

We encourage you, as a rheumatologist, to query patients about their personal stressors, such as their anxiety & its impact.

Alternatives to traditional office-based, mindfulness-based interventions include self-paced mindfulness programs accessed via smartphone applications.¹⁰ Several clinical trials have evaluated these interventions in RA patients, with noted improvements in perceived stress, anxiety and depression.¹¹

Pilot Tests

We first pilot tested the use of mobile mindfulness and meditative exercises via a popular stress-reduction app, Calm.⁴ We asked patients to use the app daily (at least five minutes) for 30 days and complete various Patient Reported Outcome Measurement Information System (PROMIS) questionnaires covering relevant areas of health-related quality of life before and after the program.

Significant reductions in fatigue were found for those who fully completed the course, with trends for improvement in perceived stress, anxiety, sleep disturbance, self-efficacy for managing symptoms and pain intensity.

Meditation Website

Through encouragement and collaboration with other rheumatologists, psychologists, mindfulness researchers and others, we built upon preliminary patient feedback and created Mindfulness for People Living with Rheumatic Disease, a mobile-device friendly website. The website was centered around common patient stressors. Meditative prescriptions were created for disease flares, medications/side effects, difficult emotions, sleep impairment, pain, fatigue, social interactions with family and friends, and body image.

Our meditations were co-created and narrated by mindfulness experts. Each meditation is approximately 10 minutes long, and each stressor has three to four meditations for a patient to practice. The site launched in late June 2021 and can be found at https://mindfulness.hopkinsrheumatology.org.

Query Your Patients

We encourage you, as a rheumatologist, to query patients about their personal stressors, such as their anxiety and its impact, which could include concerns about the COVID-19 pandemic or even include starting or remaining on a particular medication, feeling sad or depressed, or their self-image. But beyond that, offer them very specific exercises and advice that can tangibly help them start working on improving their health.

Feedback Invited

We welcome feedback and hope to grow our website as a resource for those new and old to the practice of mindfulness. To offer an analogy, we don’t prescribe someone a tumor necrosis factor (TNF) inhibitor and let them navigate the specifics; instead, we prescribe a specific TNF inhibitor at a specific dose at a specific interval. With that same sentiment, when we identify someone with stressors, we provide tangible instruction on how to engage in a program to help. We hope to gather as much patient feedback as possible on Mindfulness for People Living with Rheumatic Disease to improve upon subsequent iterations and meet the needs of our patients.

Dana DiRenzo, MD, MHS, is an assistant professor of clinical medicine at the University of Pennsylvania, Philadelphia.

References

1. Finan PH, Zautra AJ. Rheumatoid arthritis: Stress affects rheumatoid arthritis, but via what mechanisms? Nat Rev Rheumatol. 2013 Oct;9(10)569–570.
2. Walker JG, Littlejohn GO, McMurray NE, Cutolo M. Stress system response and rheumatoid arthritis: A multilevel approach. Rheumatology (Oxford). 1999 Nov;38(11):1050–1057.
3. Evers AWM, Verhoeven EWM, van Middendorp H, et al. Does stress affect the joints? Daily stressors, stress vulnerability, immune and HPA axis activity, and short-term disease and symptom fluctuations in rheumatoid arthritis. Ann Rheum Dis. 2014 Sep;73(9):1683–1688.
4. DiRenzo D, Hunt C, Sibinga E, et al. A mobile mindfulness meditation program may improve health-related quality of life for patients with rheumatic disease, a pilot study [abstract]. Arthritis Rheumatol. 2020;72(suppl 10).
5. DiRenzo DD, Craig ET, Bingham III CO, Bartlett SJ. Anxiety impacts rheumatoid arthritis symptoms and health-related quality of life even at low levels. Clin Exp Rheumatol. Nov–Dec 2020;38(6):1176–1181.
6. Tracey KJ. The inflammatory reflex. Nature. 2002 Dec 19–26;420(6917):853–859.
7. Hofmann SG, Gómez AF. Mindfulness-based interventions for anxiety and depression. Psychiatr Clin North Am. 2017 Dec;40(4):739–749.
8. Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: A systematic review and meta-analysis. JAMA Intern Med. 2014 Mar;174(3):357–368.
9. Strauss C, Cavanagh K, Oliver A, Pettman D. Mindfulness-based interventions for people diagnosed with a current episode of an anxiety or depressive disorder: A meta-analysis of randomised controlled trials. PLoS One. 2014 Apr 24;9(4):e96110.
10. Plaza I, Demarzo MMP, Herrera-Mercadal P, García-Campayo J. Mindfulness-based mobile applications: Literature review and analysis of current features. JMIR mHealth uHealth. 2013 Nov 1;1(2):e24.
11. DiRenzo D, Crespo-Bosque M, Gould N, et al. Systematic review and meta-analysis: Mindfulness-based interventions for rheumatoid arthritis. Curr Rheumatol Rep. 2018 Oct 18;20(12):75.